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					Application Form No.                                              Category

                 Admission Form for the MCA/MBA Course 2012-13

Sacred Heart Institute of Management and Technology
                                Naipalapur, Sitapur-261001

         Ph: 05862-220174 Fax: 05862-220403 Email:shimtstp@gmail.com


                                                                               Photo
Tick () whereever it is applicable and fill up.

                                      * Admission in MCA/MBA

Fill up all the particulars in BLOCK letters.



1. Name of student: (In English)



(In Hindi) ______________________________________________________________

2. Date of Birth: __________________Year______Month_________________Date_____

3. Father's Name: ___________________________Occupation:_____________________

4. Mother's Name: ___________________________Occupation:____________________

5. Guardian's Name: __________________________Occupation:____________________

6. Father's/Guardian's income (Per Month):______________________________________

7. Local Address: _________________________________________________________

                 _________________________________________________________

                Phone: _______________Nearest Police Station:____________________

8. Permanent Address: ______________________________________________________

                  Phone: ______________Nearest Police Station:____________________

9. Email ID: ______________________________________________________________

10. Religion and Caste: ______________________________________________________
11. Category: (Tick the applicable)- Gen        OBC     SC        ST      Christian

                                Ex Army men      NCC         PH         Sportsman

12. Nationality:________State (Domicile):______Place of
Birth:__________________



13. Any award or scholarship received by you (Specify):____________________________

14. Name of the college last attended: __________________________________________

15. Details of the qualifying examinations:

                                                             Marks
Examination                                                                                 Weightage
               College   Board/Univ. Subjects   Marks        Obt./Mx.     Div./Percentage
Passed                                                                                      (For off. use)
                                                             Marks
High School
or
Equivalent

Year:
                                                                                            NCC
Intermediate
                                                                                            NSS
(10+2)
                                                                                            SHIC
                                                                                            Tot.
Year:
                                                                                            Gr.Tot:
Graduation

Year:
P.G.

Year:
Others

Year:

16. Entrance Exam. (Name of exam.)__________________Year:_______Rank__________

17. Whether sportsman of State or State above level:________________________________

   (Mention the event and level):________________________________________________

18. DD/ Cheque No………………..Bank……………………………………….Date………

    ……………………..Rs………
                               DECLARATION OF THE APPLICANT

I hereby declare that all the particulars mentioned above are correct and true according to the best of my
knowledge as belief and nothing had been concealed or distorted. I agree to abide by the rules and regulations as
well as code of conduct of this institute. If at any time, I am found to have concealed or distorted any
information and misconduct. My admission shall be liable to termination without any prior notice.

PLACE :

DATE:

                                                                   SIGNATURE OF THE APPLICANT




                               DECLARATION OF THE GUARDIAN

I hereby declare that I have gone through all the information mentioned in this admission form. I assure you that
my ward will be strictly following all the rules and regulation of the institution, failing which the institution has
the legal rights to take appropriate action against my ward. Including his/her dismissal from the college.

DATE:

                                                                    SIGNATURE OF THE GUARDIAN

----------------------------------------------------------------------------------------------------------------

Verified by: _________________                                      Admitted to Course: _____________



Date:            Time:
Director:__________________________

***************************************************************************

Note: Send the completed application form with the draft for Rs. 500/- in favor of “Sacred
Heart Institute of Management and Technology” payable at SITAPUR.

				
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posted:10/3/2012
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